Patients with group A beta-hemolytic streptococcal pharyngitis have classic symptoms of tonsillar swelling/exudates, tender anterior cervical lymphadenopathy, with no cough but with fever of >38ºC.
Clinical features suggestive of a viral etiology are conjunctivitis, absence of fever, coryza, cough, diarrhea, anterior stomatitis, hoarseness, discrete ulcerative lesions, rhinorrhea and viral exanthem and/or enanthem.
Antibiotics will not be needed for every patient that presents with sore throat but it should not be withheld if the clinical condition is severe or group A beta-hemolytic streptococcus is suspected.

Principles of Therapy

Antibiotic Therapy

General Therapy Principles

With the exception of very rare infections caused by certain pathogens (Corynebacterium diphtheriae, Neisseria gonorrhoeae), antibiotic therapy is of no proven benefit for acute pharyngitis due to bacteria other than group A beta-hemolytic streptococci 

  • Viruses are the most common cause of acute pharyngitis and therefore, antibiotics are not warranted in the majority of cases of acute pharyngitis
  • Appropriate antibiotic therapy is needed for group A beta-hemolytic streptococci  because of the following reasons:
    • Prevention of nonsuppurative complications (eg acute rheumatic fever, acute post-streptococcal glomerulonephritis, reactive arthritis)
    • Prevention of suppurative complications (eg peritonsillar abscess, mastoiditis, cervical lymphadenitis)
    • Minimize transmission
    • Shorten the course of illness & allow rapid resumption of patient’s usual activities
  • If there is clinical or epidemiological evidence that results in a high index of suspicion, antimicrobial therapy may be initiated while the physician is waiting for the lab confirmation of group A beta-hemolytic streptococci pharyngitis
  • Empiric antimicrobial therapy for group A beta-hemolytic streptococci may also be warranted in the following cases:
    • Lack of laboratory access
    • Lack of or unreliable patient follow-up
    • Toxic presentation
  • Group A streptococci carriers generally do not require treatment and are not likely to infect contacts or have suppurative or nonsuppurative complications
  • If throat culture is the method of diagnosis, discontinue antibiotics if the presumptive diagnosis of group A beta-hemolytic streptococci pharyngitis is not confirmed by laboratory test results
  • When selecting antimicrobials, consider the following factors:
    • Efficacy & safety
    • Antimicrobial spectrum
    • Dosing schedule
    • Associated compliance with therapy
    • Cost
    • Potential adverse & side effects
  • Antibiotics may be given orally or parenterally, depending on the condition of the patient & compliance concerns


Symptomatic Therapy

  • Maintain adequate fluid intake
  • Warm salt water
  • Soft foods
  • Warm liquids (eg soup)
  • Throat lozenges

Antipyretics and Analgesics

  • Patient may take Paracetamol or Ibuprofen for relief of fever and/or pain
    • Paracetamol is the drug of choice for analgesia in sore throat

Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

  • Ibuprofen is a safe and effective alternative for analgesia and antipyrexia
  • Diclofenac may also be used for pain caused by acute tonsillopharyngitis
  • As NSAIDs are associated with significant risk of gastrointestinal bleeding, their routine use is not recommended

Mouth/Throat Preparations

  • Antiseptic/antibacterial preparations may be used to prevent viral infection
  • Further studies are needed to prove the efficacy of mouth/throat preparations in tonsillopharyngitis

Antibiotic Therapy

  • Drug of choice due to its proven efficacy, safety, low cost, appropriately narrow spectrum of activity & very low rates of resistance of group A beta-hemolytic streptococci to Penicillin

Amoxicillin, Ampicillin, or Amoxicillin/Clavulanic Acid

  • Efficacy appears to be equal to that of Penicillin
  • Spectrum is relatively narrow, cost is also low
  • The suspension form is considerably more palatable than Penicillin V suspension
  • Aminopenicillins should be avoided if mononucleosis is suspected since a macular rash may develop


  • First Generation
    • Eg Cefalexin
    • May be used for patients with non-type 1 Penicillin allergy
    • Have a narrow spectrum of activity; much preferred to broad-spectrum cephalosporins
    • Cefadroxil may be used for once-daily therapy of streptococcal pharyngitis
  • Second Generation
    • Eg Cefuroxime
    • May be considered in patients with non-type 1 allergy to Penicillin but generally not recommended because of their broad spectrum of activity
  • Third Generation
    • Eg Cefdinir, Cefixime, Cefpodoxime, Ceftibuten
    • May be considered in patients with non-type 1 allergy to Penicillin but generally not recommended because of their broad spectrum of activity


  • Macrolide resistance may be an issue depending on local resistance patterns
  • Erythromycin
    • Suitable alternative for patients with Penicillin allergy
    • Associated with higher rates of GI effects
    • Estolate salt should not be given to pregnant women due to reported increased risk of cholestatic hepatitis
  • Azithromycin, Clarithromycin
    • Offers no microbiologic advantage over Erythromycin, but may be better tolerated
    • Both may be used in patients allergic to penicillins
    • Azithromycin has a higher concentration in pharyngeal tissue


  • Used in rare patients with Penicillin allergy & an Erythromycin-resistant strain of Streptococcus sp

Duration of Therapy

  • A patient should receive an antimicrobial agent at a dose & for a duration that is likely to eradicate the infecting organism from the pharynx
  • 10 days of antibiotic therapy is recommended to achieve maximal rates of pharyngeal Streptococcus sp eradication
  • Some antibiotics will achieve eradication in <10 days

Non-Pharmacological Therapy

  • Washing of the hands especially after coughing or sneezing & before preparing or eating the food prevents other people from getting infected with group A streptococcus
  • Other practices of good hygiene:
    • Cover the nose and mouth with tissue while coughing or sneezing
    • Proper disposal of the used tissue in a waste basket
    • If there is no tissue, use the upper sleeve of the cloth or the elbow while coughing or sneezing
    • Wash hands with soap and water for at least 20 seconds
    • If soap is not available, use an alcohol-based hand rub instead
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